An Assistive Device for Donning Compression Stockings

  Compression therapy is the standard practice for the treatment and prevention of venous leg ulcers.^1-4 Evidence in the literature^5,6 demonstrates that compression stockings are more effective than standard short-stretch compression bandages in healing venous leg ulcers and in reducing associated pain.

  Clinicians at the Taipei Veterans General Hospital, Taipei Vein Center, Taiwan encourage patients suffering from edema, varices, or ulcers to use compression stockings (see Figure 1). However, patients frequently report difficulty donning the stockings; the experience can be particularly painful, even with the assistance of a commercially available foot slip (Sigvaris product 580, Sigvaris, Switzerland) and/or slip-on stocking aid (Sigvaris product 585, Sigvaris, Switzerland). According to clinician observation and patient anecdotal reports, the foot slip can help at the beginning of stocking application; however, it becomes less effective as the stocking comes closer to the heel, which is the area where compression stockings are most difficult to manipulate. When the slip-on-stocking aid is employed, the compression stocking is not stretched enough to don the stocking smoothly. An informal, month-long survey of 34 patients in the authors’ health institutes showed that 27 either stopped or intended to stop compression stocking therapy due to the hardship of putting on the stockings.

  To address the problem of compression stocking application, the authors redesigned the stocking aid. The focal point for change was the donning cup because a larger cup would expand the heel portion of the stocking.

Using the Redesigned Application Aid

  The newly designed stocking aid (see Figure 2) is similar to the commercially available stocking aid with 80-mm diameter donning cup (product #585, Sigvaris, Switzerland) but has a much larger donning cup. An 8-mm diameter stainless tube was utilized to construct a 120-mm diameter donning cup with a 230-mm height stand and pulling handles. Stainless steel was selected for its durability. The structure of the aid also was modified to reduce any device-related unnecessary weight.

  To use the aid during stocking application, the stocking is slipped on the cup (see Figure 2). The enlarged donning cup expands the heel portion of the stocking so the patient can insert his/her foot into the stocking up to the leg portion (see Figure 3). By holding the handle, the stocking aid and the stocking can be pulled up to the knee (see Figure 4). Then the aid is removed and the stocking is rolled up progressively. The application process takes approximately 2 to 3 minutes.

Discussion

  Evidence has demonstrated that compression stocking use can benefit venous leg ulcer healing and reduce associated pain.^5,6 The authors believe that patients seem to be more willing to use compression stockings if they can be donned without pain and difficulty.

  Minimizing pain for patients with lower leg ulcers requires the time and force necessary to unroll the stocking. Donning issues can be addressed by reducing the pulling force. However, force reduction prolongs application time. The contradiction between time and force characteristics may be explained by the principle of “prior action” noted by TRIZ theory.⁷ Prior action requires changing an object completely or partially in advance to relieve the contradiction. Redesigning the stocking aid to include a much larger donning cup allows the heel portion of the stocking to be fully expanded to alleviate any possible difficulties in application. Stocking preparation time may be longer but donning time is reduced.

  The authors have successfully designed and duplicated six stocking aids for patients with lower leg ulcers. The assistive devices may be used by hospitalized inpatients or borrowed for outpatient use. To date, the availability of the newly designed stocking aid facilitated compression stocking application in approximately 90 patients. Although users have not been formally polled, all seem to be satisfied with the new stocking aid during donning.

  The stocking aid described here is not available commercially. However, the authors believe the devices can be fabricated by skilled technicians. Furthermore, the authors hope that an interested company might purchase the design and mass-produce the new device.

Limitations

  The newly designed assistive device is a result of the ingenuity of clinicians anxious for patients to maintain compression therapy. However, slipping the stocking on the newly developed, larger cup requires more force than putting it on the currently available smaller cups. Therefore, older users or those with diminished upper body strength may need assistance to use the new device. Moreover, using the enlarged donning cup might reduce the effectiveness or durability of the compression stocking. Long-term follow-up studies are needed to assess the effectiveness and outcomes related to this device.

Conclusion

  The compression stocking has been demonstrated to be effective in helping heal venous leg ulcers and in reducing associated pain. The authors encourage patients suffering from edema, varices, or ulcers to use compression stockings as part of daily clinical practice. Because patients frequently reported difficulty donning the stockings, an existing stocking aid was redesigned. The new device includes a larger donning cup to allow the heel portion of the stocking to be fully expanded. Users report satisfaction with the new design but note that more force is required to slip the stocking on the cup before donning. Longer follow-up and assessment of the effect of the new design on life span and effectiveness of compression stockings are suggested.

1. Mekkes JR, Loots MAM, van der Wal AC, Bos JD. Causes, investigation and treatment of leg ulceration. Br J Dermatol. 2003;148:388-401.

2. Leg ulcer treatment. NHS Direct, National Health Service. Available at: www.nhs.uk. Accessed August 8, 2007.

3. Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep vein thrombosis. In: Cochrane Database of Systematic Reviews. (3):CD001484;2000.

4. Thomas SB, Toyick N, Fisher B. Graduated External Compression and the Prevention of Deep Vein Thrombosis. Bridgend, UK: Surgical Materials Testing Laboratory;1992.

5. Polignano R, Guarnera G, Bonadeo P. Evaluation of SurePress Comfort: a new compression system for the management of venous leg ulcers. J Wound Care. 2004;13(9):387-391.

6. Junger M, Wollina U, Kohnen R, Rabe E. Efficacy and tolerability of an ulcer compression stocking for therapy of chronic venous ulcer compared with a below-knee compression bandage: results from a prospective, randomized, multicentre trial. Curr Med Res Opin. 2004;20(10): 1613-1623.

7. Altshuller G. 40 Principles TRIZ Keys to Technical Innovation. Worcester, Mass: Technical Innovation Center;1998.